Microfemtotomy methods and systems

ABSTRACT

Methods and systems for performing laser-assisted surgery on an eye form one or more small anchoring capsulotomies in the lens capsule of the eye. The one or more anchoring capsulotomies are configured to accommodate corresponding anchoring features of an intraocular lens and/or to accommodate one or more drug-eluting members. A method for performing laser-assisted eye surgery on an eye having a lens capsule includes forming an anchoring capsulotomy in the lens capsule and coupling an anchoring feature of the intraocular lens with the anchoring capsulotomy. The anchoring capsulotomy is formed by using a laser to incise the lens capsule. The anchoring feature can protrude transverse to a surface of the intraocular lens that interfaces with the lens capsule adjacent to the anchoring capsulotomy.

CROSS-REFERENCES TO RELATED APPLICATIONS

This application claims priority to U.S. provisional application No.61/788,201 filed on Mar. 15, 2013, the entire contents of which areincorporated herein by reference.

BACKGROUND

Cataract extraction is one of the most commonly performed surgicalprocedures in the world. A cataract is formed by opacification of thecrystalline lens or its envelope—the lens capsule—of the eye. Thecataract obstructs passage of light through the lens. A cataract canvary in degree from slight to complete opacity. Early in the developmentof an age-related cataract the power of the lens may be increased,causing near-sightedness (myopia). Gradual yellowing and opacificationof the lens may reduce the perception of blue colors as thosewavelengths are absorbed and scattered within the crystalline lens.Cataract formation typically progresses slowly resulting in progressivevision loss. Cataracts are potentially blinding if untreated.

A common cataract treatment involves replacing the opaque crystallinelens with an artificial intraocular lens (IOL). Presently, an estimated15 million cataract surgeries per year are performed worldwide. Thecataract treatment market is composed of various segments includingintraocular lenses for implantation, viscoelastic polymers to facilitatesurgical maneuvers, and disposable instrumentation including ultrasonicphacoemulsification tips, tubing, various knives, and forceps.

Presently, cataract surgery is typically performed using a techniquetermed phacoemulsification in which an ultrasonic tip with associatedirrigation and aspiration ports is used to sculpt the relatively hardnucleus of the lens to facilitate removal through an opening made in theanterior lens capsule. The nucleus of the lens is contained within anouter membrane of the lens that is referred to as the lens capsule.Access to the lens nucleus can be provided by performing an anteriorcapsulotomy in which a small round hole is formed in the anterior sideof the lens capsule. Access to the lens nucleus can also be provided byperforming a manual continuous curvilinear capsulorhexis (CCC)procedure. After removal of the lens nucleus, a synthetic foldableintraocular lens (IOL) can be inserted into the remaining lens capsuleof the eye through a small incision. Typically, the IOL is held in placeby the edges of the anterior capsule and the capsular bag. The IOL mayalso be held by the posterior capsule, either alone or in unison withthe anterior capsule. This latter configuration is known in the field asa “Bag-in-Lens” implant.

One of the most technically challenging and critical steps in thecataract extraction procedure is providing access to the lens nucleus.The manual continuous curvilinear capsulorhexis (CCC) procedure evolvedfrom an earlier technique termed can-opener capsulotomy in which a sharpneedle was used to perforate the anterior lens capsule in a circularfashion followed by the removal of a circular fragment of lens capsuletypically in the range of 5-8 mm in diameter. The smaller thecapsulotomy, the more difficult it is to produce manually. Thecapsulotomy facilitates the next step of nuclear sculpting byphacoemulsification. Due to a variety of complications associated withthe initial can-opener technique, attempts were made by leading expertsin the field to develop a better technique for removal of the anteriorlens capsule preceding the emulsification step.

The desired outcome of the manual continuous curvilinear capsulorhexisis to provide a smooth continuous circular opening through which notonly the phacoemulsification of the nucleus can be performed safely andeasily, but also to provide for easy insertion of the intraocular lens.The resulting opening in the anterior capsule provides both a clearcentral access for tool insertion during removal of the nucleus and forIOL insertion, a permanent aperture for transmission of the image to theretina of the patient, and also support of the IOL inside the remainingcapsule that limits the potential for dislocation. The resultingreliance on the shape, symmetry, uniformity, and strength of theremaining capsule to contain, constrain, position, and maintain the IOLin the patient's eye limits the placement accuracy of the IOL, bothinitially and over time. Subsequently, a patient's refractive outcomeand resultant visual acuity are less deterministic and intrinsicallysub-optimal due to the IOL placement uncertainty. This is especiallytrue for astigmatism correcting (“toric”) and accommodating(“presbyopic”) IOLs.

Problems may also develop related to inability of the surgeon toadequately visualize the capsule due to lack of red reflex, to grasp thecapsule with sufficient security, and to tear a smooth circular openingin the capsule of the appropriate size and in the correct locationwithout creating radial rips and extensions. Also present are technicaldifficulties related to maintenance of the depth of the anterior chamberdepth after opening the capsule, small size of the pupil, or the absenceof a red reflex due to the lens opacity. Some of the problems withvisualization can be minimized through the use of dyes such as methyleneblue or indocyanine green. Additional complications may also arise inpatients with weak zonules (typically older patients) and very youngchildren that have very soft and elastic capsules, which are verydifficult to controllably and reliably rupture and tear.

The implantation of a “Bag-in-Lens” IOL typically uses anterior andposterior openings in the lens capsule of the same size. Manuallycreating matching anterior and posterior capsulotomies for the“Bag-in-Lens” configuration, however, is particularly difficult.

Many cataract patients have astigmatic visual errors. Astigmatism canoccur when the corneal curvature is unequal in all directions. IOLs canbe used to correct for astigmatism but require precise rotational andcentral placement. Additionally, IOLs are not typically used forcorrection beyond 5D of astigmatism. Many patients, however, haveastigmatic visual errors exceeding 5D. Higher correction beyond 5Dtypically requires reshaping the cornea to make it more spherical. Thereare numerous existing approaches for reshaping the cornea, includingCorneaplasty, Astigmatic Keratotomy, Corneal Relaxing Incision (CRI),and Limbal Relaxing Incision (LRI). In Astigmatic Keratotomy, CornealRelaxing Incision (CRI), and Limbal Relaxing Incision (LRI), cornealincisions are made in a well-defined manner and depth to allow thecornea to change shape to become more spherical. Presently, thesecorneal incisions are typically accomplished manually often with limitedprecision.

There are also many ongoing ophthalmic needs that are less than ideallyaddressed by the prior methods for time-release of a drug.

Thus, improved methods and systems for treating eyes are needed.

SUMMARY

Methods and apparatus are provided for the creation of either one ormore anchoring capsulotomies, which may comprise microfemtotomies. Theanchoring capsulotomies such as comprise microfemtotomies can engagewith complementary anchoring features on an intraocular lens forintracapsular, anterior, and/or posterior chamber placement. Theanchoring capsulotomies and/or microfemtotomies can also be used toanchor capsular fixated drug-eluting implants.

Although specific reference is made to the removal and treatment of acataract, the methods and apparatus as described herein can be used withone or more of many surgical procedures, for example anchoring incisionsof a non-cataractous eye of a patient.

In many embodiments, a pattern of anchoring capsulotomies is created ina lens capsule of an eye and an intraocular lens (IOL) is then coupledto the lens capsule by mechanically engaging anchoring features of theIOL to the pattern of anchoring capsulotomies. The IOL may comprise annon-accommodating IOL or an accommodating IOL. And in many embodiments,an axial orientation to be established between the TOL and the lenscapsule is determined. The eye may comprise a rotational axis, and thepattern can be located so as to align an axis the IOL or other implantwith an intended axis of the eye. In many embodiments, the IOL maycomprise an aberration correction, for example astigmatism or otheraberration along an axis such as a higher order aberration, and thepattern of anchoring features can be placed on the eye at locations thatalign the axis of the IOL or other implant with the axis of the eye. Inmany embodiments, an axis of an astigmatic correction is determined, andthe pattern rotated on the eye to locate the small capsulotomies toreceive features of the IOL such that the IOL is placed at a visioncorrecting axis and rotation of the IOL away from the axis is inhibitedwhen placed. Alternatively or in combination, the small capsulotomiescan be located so as to align a center of the IOL with the optical axisof the eye. In many embodiments, a processor comprises a computerreadable medium having instructions embodied thereon to determineangular locations of the small capsulotomies on the eye in order toalign an axis of the IOL or other implant with the axis of the eye. Inmany embodiments, the anchoring features comprise a pre-determinedangular orientation with respect to the aberration correcting axis ofthe IOL, and the small capsulotomies are located to align the aberrationcorrecting axis of the IOL with the aberration axis of the eye.

The anchoring capsulotomies can be located to accomplish the determinedaxial orientation upon assembly or unrolling of the IOL with the lenscapsule. Accordingly, an IOL can be held in a desired position andorientation relative to the lens capsule, thereby avoiding undesirableaspects related to having an TOL shift position and/or orientationrelative to the lens capsule. The IOL can also be located in differentlocations within the eye including, but not limited to, in an anteriorchamber of the eye, in a capsular bag of the eye, on the anterior sideof a posterior capsule of the eye, or on the posterior side of ananterior capsule of the eye. Such flexibility in the location of the IOLwithin the eye provides increased treatment flexibility, such as theability to install a second IOL anteriorly to an IOL that was previouslyimplanted.

In one aspect, a method of ophthalmic intervention is provided. Themethod includes creating a pattern of anchoring capsulotomies in a lenscapsule of an eye. The pattern of anchoring capsulotomies is configuredto be mechanically coupled to anchoring features of an intraocular lens(IOL). The IOL is then coupled to the lens capsule by mechanicallyengaging the anchoring features of the IOL with the pattern of anchoringcapsulotomies

In another aspect, “micro-femtotomies”, or small capsulotomies, areformed in the lens capsule to position and orient an IOL. The TOL caneven be “piggybacked” above an existing IOL. Piggybacking an IOL abovean existing TOL may be desired when an optical adjustment is requiredand it is desired to avoid the intrusiveness and risks of removing theoriginal IOL. Such an optical adjustment may be required as a result of,for example, the growth of a child's eyes, etc. If the original TOL isseated well, but not in the right place, a well positioned piggyback IOLcan be used to balance the patient's optical system. The overlaying IOLcan provide cylindrical/toric optical corrections, can be made thickerin one region and thinner in another, or can utilize refractive indexprofiles for aberration control.

The small capsulotomies can be made using a variety of shapes.Non-radially symmetric shapes such as lines, rectangles, squares, andellipses can be used to complement features on the device to beimplanted in order to hold the features.

In many embodiments, methods and apparatus are provided for improveddelivery of therapeutic agents such as drugs. Non-limiting examples ofapplications for the methods disclosed herein for time-release of a druginclude glaucoma medications, anti-vascular endothelial growth factor(VEGF) treatments, and the release of therapeutic agents such asdiclofenac sodium, ketorolac tromethamine, and cytotoxic LEC-specificgenes to combat PCO. Additional non-limiting examples include othercompounds that improve the chemical diffusion or pumping of the cornea.Typical time-release drug placement is achieved by means of theirinjection into a surgically produced pocket within the eye, whichprovides a comparatively unstable platform. In contrast, an improvedapproach is provided that does not involve sutures or other physicalrestraints. In an embodiment, a microfemtotomy is used to support adrug-eluting device or pellet.

The creation of such small capsulotomies, especially with smoothlyrounded edges, is practically impossible to perform manually.Additionally, plasma-mediated (or photo disruptive) capsulotomies areactually stronger than manually created capsulorhexses. This is asurprising result because there is a bounty of medical and scientificliterature reporting that attempts to use energy-driven devices forcapsulotomy have always yielded inferior incision edge strength whencompared to manual capsulorhexsis. The increased strength ofplasma-mediated capsulotomies further enhances the importance of thepresent inventive approach to the creation of microfemtotomy, or smalllaser-created capsulotomy.

BRIEF DESCRIPTION OF THE DRAWINGS

A better understanding of the features and advantages of the presentdisclosure will be obtained by reference to the following detaileddescription that sets forth illustrative embodiments, in which theprinciples of the disclosure are utilized, and the accompanying drawingsof which:

FIG. 1 shows a schematic representation of an embodiment of a systemcapable of creating anchoring capsulotomies, in accordance with manyembodiments;

FIG. 2 shows a schematic representation of another embodiment of asystem, which utilizes optical multiplexing to deliver treatment andimaging light, capable of creating anchoring capsulotomies, inaccordance with many embodiments;

FIG. 3 shows a schematic representation of another embodiment of asystem, which utilizes an alternate imaging system, capable of creatinganchoring capsulotomies, in accordance with many embodiments;

FIG. 4 shows a schematic representation of another embodiment of asystem, which utilizes another alternate imaging system configuration,capable of creating anchoring capsultomies, in accordance with manyembodiments;

FIGS. 5A and 5B shows example anchoring capsulotomies for constrainingan IOL, in accordance with many embodiments;

FIGS. 6A and 6B show an IOL being constrained within the lens capsuleusing anchoring capsulotomies, in accordance with an embodiment, inaccordance with many embodiments;

FIGS. 7A through 7C show example anchoring capsulotomy shapes, includingbuttonhole incisions, in accordance with many embodiments;

FIGS. 8A and 8B show an IOL being implanted over an existing lens usinganchoring capsulotomies, in accordance with an embodiment, in accordancewith many embodiments;

FIGS. 9A through 9D show examples of different IOL anchoring capsulotomyconfigurations, in accordance with many embodiments;

FIG. 10 shows using an anchoring capsulotomy to accommodate an implanteddrug-eluting device, in accordance with an embodiment, in accordancewith many embodiments;

FIG. 11 shows an alternate configuration of an implantable drug-elutingdevice that is accommodated by an anchoring capsulotomy, in accordancewith many embodiments;

FIG. 12 shows another alternate configuration of an implantabledrug-eluting device that is accommodated by an anchoring capsulotomy, inaccordance with many embodiments;

FIGS. 13A and 13B show an alternate configuration of an implanteddrug-eluting device that is accommodated in different locations byanchoring capsulotomies, in accordance with many embodiments;

FIG. 14 illustrates a method for creating an anchoring capsulotomy andcoupling an anchoring feature of an intraocular lens with the anchoringcapsulotomy, in accordance with many embodiments, in accordance withmany embodiments;

FIG. 15 illustrates a method for creating an anchoring capsulotomy andremovably coupling a drug-eluting member to the anchoring capsulotomy,in accordance with many embodiments;

FIG. 16 illustrates a method 650 of ophthalmic intervention, inaccordance with many embodiments.

DETAILED DESCRIPTION

In the following description, various embodiments of the presentdisclosure will be described. For purposes of explanation, specificconfigurations and details are set forth in order to provide a thoroughunderstanding of the embodiments. However, it will also be apparent toone skilled in the art that the present disclosure may be practicedwithout the specific details. Furthermore, well-known features may beomitted or simplified in order not to obscure the embodiment beingdescribed.

Methods and systems for performing laser-assisted eye surgery areprovided in which one or more small anchoring capsulotomies are formedin the lens capsule of an eye. The one or more anchoring capsulotomiescan be used to accommodate one or more corresponding anchoring featuresof an intraocular lens (IOL), thereby restraining the IOL relative tothe lens capsule. An anchoring capsulotomy can also be used toaccommodate a drug-eluting member to deliver a therapeutic agent overtime. The anchoring capsulotomies can also be used to restrain andorient a “piggy back” IOL anterior to an existing optical structure(e.g., a first IOL, a natural lens) that is restrained by the lenscapsule.

The methods disclosed herein can be implemented by a system thatprojects or scans an optical beam into a patient's eye 68, such assystem 2 shown in FIG. 1. System 2 includes an ultrafast (UF) lightsource 4 (e.g., a femtosecond laser). Using system 2, a beam can bescanned in the patient's eye 68 in three dimensions: X, Y, Z.Short-pulsed laser light can be focused into eye tissue to producedielectric breakdown to cause photo disruption around the focal point(the focal zone), thereby rupturing the tissue in the vicinity of thephoto-induced plasma. In this embodiment, the wavelength of the laserlight can vary between 800 nm to 1200 nm and the pulse width of thelaser light can vary from 10 fs to 10000 fs. The pulse repetitionfrequency can also vary from 10 kHz to 500 kHz. Safety limits withregard to unintended damage to non-targeted tissue bound the upper limitwith regard to repetition rate and pulse energy. And threshold energy,time to complete the procedure, and stability bound the lower limit forpulse energy and repetition rate. The peak power of the focused spot inthe eye 68 and specifically within the crystalline lens 69 and anteriorcapsule of the eye is sufficient to produce optical breakdown andinitiate a plasma-mediated ablation process. Although near-infraredwavelengths are used in many embodiments because linear opticalabsorption and scattering in biological tissue is reduced fornear-infrared wavelengths, many alternative embodiments comprise one ormore of visible, ultraviolet or infrared light energy. As a non-limitingexample, laser 4 can be a repetitively pulsed 1035 nm device thatproduces 500 fs pulses at a repetition rate of 100 kHz and individualpulse energy in the 1 to 20 micro joule range. In general, any suitablelaser having any suitable parameters can be used. An example of such asuitable system is described U.S. patent application Ser. No.11/328,970, in the name of Blumenkranz et al., entitled “METHOD ANDAPPARATUS FOR PATTERNED PLASMA-MEDIATED LASR TREPHENATION OF THE LENSAND CAPSULE IN THREE DIMENSOINAL PHACO-SEGMENTATION”, Pub. No.2006/0195076, the entire disclosure of which is incorporated herein byreference. Embodiments of an ultraviolet laser suitable for combinationin accordance with embodiments described herein are described in U.S.patent application Ser. No. 12/987069, in the name of Schuele et al.,entitled, “METHOD AND SYSTEM FOR MODIFYING EYE TISSUE AND INTRAOCULARLENSES”, Pub. No. 2011/0172649, the entire disclosure of which isincorporated herein by reference.

The laser 4 is controlled by control electronics 300, via an input andoutput device 302, to create optical beam 6. Control electronics 300 maycomprise a processor such as a computer, microcontroller, etc. In thisexample, the controller 300 controls the entire system and data is movedthrough input/output device IO 302. A graphical user interface GUI 304can be used to set system operating parameters, process user input (UI)306, and display gathered information such as images of ocularstructures. The GUI 304 and UI 306 may comprise components of a knowncomputer system, for example one or more of a display, a touch screendisplay, key board, a pointer or a mouse, for example. The controlelectronics may comprise one or more processors of a computer system,for example.

The control electronics 300 can be configured in one or more of manyways, and may comprise a processor having a tangible medium havinginstructions of a computer program embodied thereon. In manyembodiments, the tangible medium comprises a computer readable memoryhaving instructions of a computer readable medium embodied thereon.Alternatively or in combination, the control electronic may comprisearray logic such as a gate array, a programmable gate array, for fieldprogrammable gate array to implement one or more instructions asdescribed herein. The instructions of the tangible medium can beimplemented by the processor of the control electronics.

The generated UF light beam 6 proceeds towards the patient eye 68passing through a half-wave plate 8 and a linear polarizer, 10. Thepolarization state of the beam can be adjusted so that the desiredamount of light passes through the half-wave plate 8 and the linearpolarizer 10, which together act as a variable attenuator for the UFbeam 6. Additionally, the orientation of the linear polarizer 10determines the incident polarization state incident upon a beam combiner34, thereby optimizing the beam combiner 34 throughput.

The UF light beam 6 proceeds through a system-controlled shutter 12, anaperture 14, and a pickoff device 16. The system-controlled shutter 12ensures on/off control of the laser for procedural and safety reasons.The aperture 14 sets an outer useful diameter for the UF light beam 6and the pickoff device 16 monitors the resulting beam. The pickoffdevice 16 includes a partially reflecting mirror 20 and a detector 18.Pulse energy, average power, or a combination can be measured using thedetector 18. Output from the detector 18 can be used for feedback to thehalf-wave plate 8 for attenuation and to verify whether thesystem-controlled shutter 12 is open or closed. In addition, thesystem-controlled shutter 12 can have position sensors to provide aredundant state detection.

The beam passes through a beam conditioning stage 22, in which beamparameters such as beam diameter, divergence, circularity, andastigmatism can be modified. In this illustrative example, the beamconditioning stage 22 includes a two-element beam expanding telescopecomprised of spherical optics 24, 26 in order to achieve the intendedbeam size and collimation. Although not illustrated here, an anamorphicor other optical system can be used to achieve the desired beamparameters. The factors used to determine these beam parameters includethe output beam parameters of the laser, the overall magnification ofthe system, and the desired numerical aperture (NA) at the treatmentlocation. In addition, the beam conditioning stage 22 can be used toimage aperture 14 to a desired location (e.g., the center locationbetween a 2-axis scanning device 50 described below). In this way, theamount of light that makes it through the aperture 14 is assured to makeit through the scanning system. The pickoff device 16 is then a reliablemeasure of the usable light.

After exiting the beam conditioning stage 22, the beam 6 reflects off offold mirrors 28, 30, 32. These mirrors can be adjustable for alignmentpurposes. The beam 6 is then incident upon the beam combiner 34. Thebeam combiner 34 reflects the UF beam 6 (and transmits both the imaging,in this exemplary case, an optical coherence tomography (OCT) beam 114,and an aim 202 beam described below). For efficient beam combineroperation, the angle of incidence is preferably kept below 45 degreesand the polarization of the beams is fixed where possible. For the UFbeam 6, the orientation of the linear polarizer 10 provides fixedpolarization. Although OCT is used as the imaging modality in thisnon-limiting example, other approaches, such as Purkinje imaging,Scheimpflug imaging, confocal or nonlinear optical microscopy,fluorescence imaging, ultrasound, structured light, stereo imaging, orother known ophthalmic or medical imaging modalities and/or combinationsthereof may be employed.

Following the beam combiner 34, the beam 6 continues onto a z-adjust orZ scan device 40. In this illustrative example the z-adjust 40 includesa Galilean telescope with two lens groups 42, 44 (each lens groupincludes one or more lenses). The lens group 42 moves along the z-axisabout the collimation position of the telescope. In this way, the focusposition of the spot in the patient's eye 68 moves along the z-axis asindicated. In general, there is a fixed linear relationship between themotion of lens 42 and the motion of the focus. In this case, thez-adjust telescope has an approximate 2× beam expansion ratio and a 1:1relationship of the movement of lens 42 to the movement of the focus.Alternatively, the lens group 44 could be moved along the z-axis toactuate the z-adjust, and scan. The z-adjust 40 is the z-scan device fortreatment in the eye 68. It can be controlled automatically anddynamically by the system and selected to be independent or to interplaywith the X-Y scan device described next. The mirrors 36, 38 can be usedfor aligning the optical axis with the axis of the z-adjust device 40.

After passing through the z-adjust device 40, the beam 6 is directed tothe x-y scan device 50 by mirrors 46, 48. The mirrors 46, 48 can beadjustable for alignment purposes. X-Y scanning is achieved by thescanning device 50 preferably using two mirrors 52, 54 under the controlof the control electronics 300, which rotate in orthogonal directionsusing motors, galvanometers, or any other well known optic movingdevice. The mirrors 52, 54 are located near the telecentric position ofan objective lens 58 and a contact lens 66 combination described below.Tilting the mirrors 52, 54 changes the resulting direction of the beam6, causing lateral displacements in the plane of UF focus located in thepatient's eye 68. The objective lens 58 may be a complex multi-elementlens element, as shown, and represented by lenses 60, 62, and 64. Thecomplexity of the objective lens 58 will be dictated by the scan fieldsize, the focused spot size, the available working distance on both theproximal and distal sides of objective lens 58, as well as the amount ofaberration control. An f-theta objective lens 58 of focal length 60 mmgenerating a spot size of 10 μm, over a field of 10 mm, with an inputbeam size of 15 mm diameter is an example. Alternatively, X-Y scanningby the scanning device 50 may be achieved by using one or more moveableoptical elements (e.g., lenses, gratings), which also may be controlledby the control electronics 300, via the input and output device 302.

The scanning device 50 under the control of the control electronics 300can automatically generate the aiming and treatment scan patterns. Suchpatterns may be comprised of a single spot of light, multiple spots oflight, a continuous pattern of light, multiple continuous patterns oflight, and/or any combination of these. In addition, the aiming pattern(using the aim beam 202 described below) need not be identical to thetreatment pattern (using the light beam 6), but preferably at leastdefines its boundaries in order to assure that the treatment light isdelivered only within the desired target area for patient safety. Thismay be done, for example, by having the aiming pattern provide anoutline of the intended treatment pattern. This way the spatial extentof the treatment pattern may be made known to the user, if not the exactlocations of the individual spots themselves, and the scanning thusoptimized for speed, efficiency and accuracy. The aiming pattern mayalso be made to be perceived as blinking in order to further enhance itsvisibility to the user.

An optional contact lens 66, which can be any suitable ophthalmic lens,can be used to help further focus the light beam 6 into the patient'seye 68 while helping to stabilize eye position. The positioning andcharacter of the light beam 6 and/or the scan pattern the light beam 6forms on the eye 68 may be further controlled by use of an input devicesuch as a joystick, or any other appropriate user input device (e.g.,GUI 304) to position the patient and/or the optical system.

The UF laser 4 and the control electronics 300 can be set to target thetargeted structures in the eye 68 and ensure that the light beam 6 willbe focused where appropriate and not unintentionally damage non-targetedtissue. Imaging modalities and techniques described herein, such asthose mentioned above, or ultrasound may be used to determine thelocation and measure the thickness of the lens and lens capsule toprovide greater precision to the laser focusing methods, including 2Dand 3D patterning. Laser focusing may also be accomplished using one ormore methods including direct observation of an aiming beam, or otherknown ophthalmic or medical imaging modalities, such as those mentionedabove, and/or combinations thereof. In the embodiment of FIG. 1, an OCTdevice 100 is described, although other modalities are within the scopeof the present invention. An OCT scan of the eye will provideinformation about the axial location of the anterior and posterior lenscapsule, the boundaries of the cataract nucleus, as well as the depth ofthe anterior chamber. This information is then loaded into the controlelectronics 300, and used to program and control the subsequentlaser-assisted surgical procedure. The information may also be used todetermine a wide variety of parameters related to the procedure such as,for example, the upper and lower axial limits of the focal planes usedfor cutting the lens capsule and segmentation of the lens cortex andnucleus, and the thickness of the lens capsule among others.

The OCT device 100 in FIG. 1 includes a broadband or a swept lightsource 102 that is split by a fiber coupler 104 into a reference arm 106and a sample arm 110. The reference arm 106 includes a module 108containing a reference reflection along with suitable dispersion andpath length compensation. The sample arm 110 of the OCT device 100 hasan output connector 112 that serves as an interface to the rest of theUF laser system. The return signals from both the reference and samplearms 106, 110 are then directed by coupler 104 to a detection device128, which employs a time domain detection technique, a frequencydetection technique, or a single point detection technique. In FIG. 1, afrequency domain technique is used with an OCT wavelength of 830nm andbandwidth of 100 nm.

After exiting the connector 112, the OCT beam 114 is collimated using alens 116. The size of the collimated OCT beam 114 is determined by thefocal length of the lens 116. The size of the beam 114 is dictated bythe desired NA at the focus in the eye and the magnification of the beamtrain leading to the eye 68. Generally, the OCT beam 114 does notrequire as high an NA as the UF light beam 6 in the focal plane andtherefore the OCT beam 114 is smaller in diameter than the UF light beam6 at the beam combiner 34 location. Following the collimating lens 116is an aperture 118, which further modifies the resultant NA of the OCTbeam 114 at the eye. The diameter of the aperture 118 is chosen tooptimize OCT light incident on the target tissue and the strength of thereturn signal. A polarization control element 120, which may be activeor dynamic, is used to compensate for polarization state changes. Thepolarization state changes may be induced, for example, by individualdifferences in corneal birefringence. Mirrors 122, 124 are then used todirect the OCT beam 114 towards beam combiners 126, 34. Mirrors 122, 124can be adjustable for alignment purposes and in particular foroverlaying of the OCT beam 114 to the UF light beam 6 subsequent to thebeam combiner 34. Similarly, the beam combiner 126 is used to combinethe OCT beam 114 with the aim beam 202 as described below.

Once combined with the UF light beam 6 subsequent to beam combiner 34,the OCT beam 114 follows the same path as the UF light beam 6 throughthe rest of the system. In this way, the OCT beam 114 is indicative ofthe location of the UF light beam 6. The OCT beam 114 passes through thez-scan 40 and x-y scan 50 devices then the objective lens 58, thecontact lens 66, and on into the eye 68. Reflections and scatter off ofstructures within the eye provide return beams that retrace back throughthe optical system, into the connector 112, through the coupler 104, andto the OCT detector 128. These return back reflections provide OCTsignals that are in turn interpreted by the system as to the location inX, Y, and Z of UF light beam 6 focal location.

The OCT device 100 works on the principle of measuring differences inoptical path length between its reference and sample arms. Therefore,passing the OCT beam 114 through the z-adjust device 40 does not extendthe z-range of the OCT system 100 because the optical path length doesnot change as a function of movement of the lens group 42. The OCTsystem 100 has an inherent z-range that is related to the detectionscheme, and in the case of frequency domain detection it is specificallyrelated to the spectrometer and the location of the reference arm 106.In the case of OCT system 100 used in FIG. 1, the z-range isapproximately 1-2 mm in an aqueous environment. Extending this range toat least 4 mm involves the adjustment of the path length of thereference arm within OCT system 100. Passing the OCT beam 114 in thesample arm through the z-scan of z-adjust device 40 allows foroptimization of the OCT signal strength. This is accomplished byfocusing the OCT beam 114 onto the targeted structure whileaccommodating the extended optical path length by commensuratelyincreasing the path within the reference arm 106 of OCT system 100.

Because of the fundamental differences in the OCT measurement withrespect to the UF focus device due to influences such as immersionindex, refraction, and aberration, both chromatic and monochromatic,care must be taken in analyzing the OCT signal with respect to the UFbeam focal location. A calibration or registration procedure as afunction of X, Y, and Z should be conducted in order to match the OCTsignal information to the UF focus location and also to the relative toabsolute dimensional quantities.

Observation of an aim beam may also be used to assist the user todirecting the UF laser focus. Additionally, an aim beam visible to theunaided eye in lieu of the infrared OCT beam and the UF light beam canbe helpful with alignment provided the aim beam accurately representsthe infrared beam parameters. An aim subsystem 200 is employed in theconfiguration shown in FIG. 1. The aim beam 202 is generated by an aimbeam light source 201, such as a helium-neon laser operating at awavelength of 633 nm. Alternatively a laser diode in the 630-650 nmrange can be used. An advantage of using the helium neon 633 nm beam isits long coherence length, which would enable the use of the aim path asa laser unequal path-length interferometer (LUPI) to measure the opticalquality of the beam train, for example.

Once the aim beam light source 201 generates the aim beam 202, the aimbeam 202 is collimated using a lens 204. The size of the collimated beamis determined by the focal length of the lens 204. The size of the aimbeam 202 is dictated by the desired NA at the focus in the eye and themagnification of the beam train leading to the eye 68. Generally, theaim beam 202 should have close to the same NA as the UF light beam 6 inthe focal plane and therefore the aim beam 202 is of similar diameter tothe UF light beam 6 at the beam combiner 34. Because the aim beam 202 ismeant to stand-in for the UF light beam 6 during system alignment to thetarget tissue of the eye, much of the aim path mimics the UF path asdescribed previously. The aim beam 202 proceeds through a half-waveplate 206 and a linear polarizer 208. The polarization state of the aimbeam 202 can be adjusted so that the desired amount of light passesthrough the polarizer 208. The half-wave plate 206 and the linearpolarizer 208 therefore act as a variable attenuator for the aim beam202. Additionally, the orientation of polarizer 208 determines theincident polarization state incident upon the beam combiners 126, 34,thereby fixing the polarization state and allowing for optimization ofthe throughput of the beam combiners 126, 34. Of course, if asemiconductor laser is used as the aim beam light source 200, the drivecurrent can be varied to adjust the optical power.

The aim beam 202 proceeds through a system-controlled shutter 210 and anaperture 212. The system-controlled shutter 210 provides on/off controlof the aim beam 202. The aperture 212 sets an outer useful diameter forthe aim beam 202 and can be adjusted appropriately. A calibrationprocedure measuring the output of the aim beam 202 at the eye can beused to set the attenuation of aim beam 202 via control of the polarizer206.

The aim beam 202 next passes through a beam-conditioning device 214.Beam parameters such as beam diameter, divergence, circularity, andastigmatism can be modified using one or more well known beamingconditioning optical elements. In the case of the aim beam 202 emergingfrom an optical fiber, the beam-conditioning device 214 can simplyinclude a beam-expanding telescope with two optical elements 216, 218 inorder to achieve the intended beam size and collimation. The finalfactors used to determine the aim beam parameters such as degree ofcollimation are dictated by what is necessary to match the UF light beam6 and the aim beam 202 at the location of the eye 68. Chromaticdifferences can be taken into account by appropriate adjustments of thebeam conditioning device 214. In addition, the optical system 214 isused to image aperture 212 to a desired location such as a conjugatelocation of the aperture 14.

The aim beam 202 next reflects off of fold mirrors 220, 222, which arepreferably adjustable for alignment registration to the UF light beam 6subsequent to the beam combiner 34. The aim beam 202 is then incidentupon the beam combiner 126 where the aim beam 202 is combined with theOCT beam 114. The beam combiner 126 reflects the aim beam 202 andtransmits the OCT beam 114, which allows for efficient operation of thebeam combining functions at both wavelength ranges. Alternatively, thetransmit function and the reflect function of the beam combiner 126 canbe reversed and the configuration inverted. Subsequent to the beamcombiner 126, the aim beam 202 along with the OCT beam 114 is combinedwith the UF light beam 6 by the beam combiner 34.

A device for imaging the target tissue on or within the eye 68 is shownschematically in FIG. 1 as an imaging system 71. The imaging system 71includes a camera 74 and an illumination light source 86 for creating animage of the target tissue. The imaging system 71 gathers images thatmay be used by the control electronics 300 for providing patterncentering about or within a predefined structure. The illumination lightsource 86 is generally broadband and incoherent. For example, the lightsource 86 can include multiple LEDs as shown. The wavelength of theillumination light source 86 is preferably in the range of 700 nm to 750nm, but can be anything that is accommodated by a beam combiner 56,which combines the viewing light with the beam path for the UF lightbeam 6 and the aim beam 202 (beam combiner 56 reflects the viewingwavelengths while transmitting the OCT and UF wavelengths). The beamcombiner 56 may partially transmit the aim wavelength so that the aimbeam 202 can be visible to the viewing camera 74. An optionalpolarization element 84 in front of the light source 86 can be a linearpolarizer, a quarter wave plate, a half-wave plate or any combination,and is used to optimize signal. A false color image as generated by thenear infrared wavelength is acceptable.

The illumination light from the light source 86 is directed down towardsthe eye using the same objective lens 58 and the contact lens 66 as theUF light beam 6 and the aim beam 202. The light reflected and scatteredoff of various structures in the eye 68 are collected by the same lenses58, 66 and directed back towards the beam combiner 56. At the beamcombiner 56, the return light is directed back into the viewing path viabeam combiner 56 and a mirror 82, and on to the viewing camera 74. Theviewing camera 74 can be, for example but not limited to, any siliconbased detector array of the appropriately sized format. A video lens 76forms an image onto the camera's detector array while optical elements80, 78 provide polarization control and wavelength filteringrespectively. An aperture or iris 81 provides control of imaging NA andtherefore depth of focus and depth of field. A small aperture providesthe advantage of large depth of field that aids in the patient dockingprocedure. Alternatively, the illumination and camera paths can beswitched. Furthermore, the aim light source 200 can be made to emitinfrared light that would not be directly visible, but could be capturedand displayed using the imaging system 71.

Coarse adjust registration is usually needed so that when the contactlens 66 comes into contact with the cornea of the eye 68, the targetedstructures are in the capture range of the X, Y scan of the system.Therefore a docking procedure is preferred, which preferably takes inaccount patient motion as the system approaches the contact condition(i.e. contact between the patient's eye 68 and the contact lens 66). Theviewing system 71 is configured so that the depth of focus is largeenough such that the patient's eye 68 and other salient features may beseen before the contact lens 66 makes contact with the eye 68.

Preferably, a motion control system 70 is integrated into the overallsystem 2, and may move the patient, the system 2 or elements thereof, orboth, to achieve accurate and reliable contact between the contact lens66 and the eye 68. Furthermore, a vacuum suction subsystem and flangemay be incorporated into the system 2, and used to stabilize the eye 68.Alignment of the eye 68 to the system 2 via the contact lens 66 can beaccomplished while monitoring the output of the imaging system 71, andperformed manually or automatically by analyzing the images produced bythe imaging system 71 electronically by means of the control electronics300 via the IO 302. Force and/or pressure sensor feedback can also beused to discern contact, as well as to initiate the vacuum subsystem. Analternate patient interface can also be used, such as that described inU.S. patent application Ser. No. 13/225,373, which is incorporatedherein by reference.

An alternative beam combining configuration is shown in the alternateembodiment of FIG. 2. For example, the passive beam combiner 34 in FIG.1 can be replaced with an active combiner 140 as shown in FIG. 2. Theactive beam combiner 140 can be a moving or dynamically controlledelement such as a galvanometric scanning mirror, as shown. The activecombiner 140 changes its angular orientation in order to direct eitherthe UF light beam 6 or the combined aim and OCT beams 202,114 towardsthe scanner 50 and eventually towards the eye 68 one at a time. Theadvantage of the active combining technique is that it avoids thedifficulty of combining beams with similar wavelength ranges orpolarization states using a passive beam combiner. This ability istraded off against the ability to have simultaneous beams in time andpotentially less accuracy and precision due to positional tolerances ofactive beam combiner 140.

Another alternate embodiment is shown in FIG. 3 and is similar to thatof FIG. 1 but utilizes an alternate approach to the OCT 100. In FIG. 3,an OCT 101 is the same as the OCT 100 in FIG. 1, except that thereference arm 106 has been replaced by a reference arm 132. Thisfree-space OCT reference arm 132 is realized by including a beamsplitter 130 after the lens 116. The reference beam 132 then proceedsthrough a polarization controlling element 134 and then onto a referencereturn module 136. The reference return module 136 contains theappropriate dispersion and path length adjusting and compensatingelements and generates an appropriate reference signal for interferencewith the sample signal. The sample arm of OCT 101 now originatessubsequent to the beam splitter 130. Potential advantages of this freespace configuration include separate polarization control andmaintenance of the reference and sample arms. The fiber based beamsplitter 104 of the OCT 101 can also be replaced by a fiber basedcirculator. Alternately, both the OCT detector 128 and the beam splitter130 might be moved together as opposed to the reference return module136.

FIG. 4 shows another alternative embodiment for combining the OCT beam114 and the UF light beam 6. In FIG. 4, an OCT 156 (which can includeeither of the configurations of OCT 100 or 101) is configured such thatan OCT beam 154 output by the OCT 156 is coupled to the UF light beam 6after the z-scan device 40 using a beam combiner 152. In this way, theOCT beam 154 avoids using the z-scan device 40. This allows the OCT 156to possibly be folded into the beam more easily and shortening the pathlength for more stable operation. This OCT configuration is at theexpense of an optimized signal return strength as discussed with respectto FIG. 1. There are many possibilities for the configuration of the OCTinterferometer, including time and frequency domain approaches, singleand dual beam methods, swept source, etc, as described in U.S. Pat. Nos.5,748,898; 5,748,352; 5,459,570; 6,111,645; and 6,053,613 (which areincorporated herein by reference.)

The system 2 can be set to locate the surface of the capsule and ensurethat the light beam 6 will be focused on the lens capsule at all pointsof the desired opening. Imaging modalities and techniques describedherein, such as for example, Optical Coherence Tomography (OCT), such asPurkinje imaging, Scheimpflug imaging, confocal or nonlinear opticalmicroscopy, fluorescence imaging, ultrasound, structured light, stereoimaging, or other known ophthalmic or medical imaging modalities and/orcombinations thereof may be used to determine the shape, geometry,perimeter, boundaries, and/or 3-dimensional location of the lens andlens capsule to provide greater precision to the laser focusing methods,including 2D and 3D patterning. Laser focusing may also be accomplishedusing one or more methods including direct observation of an aimingbeam, or other known ophthalmic or medical imaging modalities andcombinations thereof, such as but not limited to those defined above.

Optical imaging of the anterior chamber and lens can be performed on thelens using the same laser and/or the same scanner used to produce thepatterns for cutting. This scan will provide information about the axiallocation and shape (and even thickness) of the anterior and posteriorlens capsule, the boundaries of the cataract nucleus, as well as thedepth of the anterior chamber. This information may then be loaded intothe laser 3-D scanning system or used to generate a three dimensionalmodel/representation/image of the anterior chamber and lens of the eye,and used to define the patterns used in the surgical procedure.

The above-described systems may be used to incise the capsule of thelens of an eye to produce an anchoring capsulotomy. An example is thearray of four anchoring capsulotomies in the lens capsule have beenplaced at regular spacing circumferentially about a larger capsulotomythat may be used to mate with complementary anchoring features on an IOLthat is shown in FIG. 5A. In this example, capsule 402 is incised usingthe system described above to create anchoring capsulotomies 432A-432D.These microfemtotomies are disposed about the perimeter of a centralcapsulotomy 400. The central capsulotomy 400 is not required to practicethe present invention, but is given as a non-limiting example for thecases where an IOL 440 is to be implanted above an existing IOL (notshown) for which central capsulotomy 400 pre-exists or into the capsuleitself where central capsulotomy 400 is used in the traditional mannerto provide instrumentation access for removing the crystalline lensduring cataract surgery.

In many embodiments the eye comprises aberrations that extend along anaberration axis 405. The aberration axis may comprise one or more ofmany axes suitable to describe an aberration of the eye such asastigmatism and higher order aberrations, for example. In manyembodiments, aberration axis 405 will extend along a horizontal axis ofthe eye or along a vertical axis of the eye. With astigmatism, a firstaxis may extend in a first direction and a second axis may extend in asecond direction perpendicular to the first direction. In manyembodiments, aberration axis 405 will extend away from a horizontal axisof the eye and away from a vertical axis of the eye.

FIG. 5B shows an IOL 440 that is configured to be constrained via theanchoring capsulotomies 432A-432D. In this non-limiting example, the IOL440 is configured with anchors 442 that are configured to engage theanchoring capsulotomies 432A-432D, as well as struts 450. The struts 450are intended to maintain a prescribed distance between the IOL 440 andthe capsule 402. This is discussed in more detail in the followingsection on posterior capsule opacification, also known as “secondarycataract.” The anchoring capsulotomy incisions may be too small to becreated reliably by hand. Likewise, the required placement of theanchoring capsulotomy incisions can be very precise. There is a myriadof possibilities for employing such mating anchoring capsulotomies andIOL anchoring features that provide for the improved placement of an IOLrelative to the lens capsule of the eye of a patient. European Pat.Appl. No. EPP16613A-100927 discloses similar IOLs, which are includedherein by reference.

In many embodiments, IOL 440 comprises a shape to correct aberrations ofthe eye and an aberration correcting axis 445. The aberration correctingaxis 445 can be aligned in relation to anchors 442, for example with apre-determined alignment with respect to anchors 442. The anchors 442can be located so as to align the aberration correcting axis 445 withthe aberration axis 405 in order to treat an aberration of the eye suchas one or more of astigmatism or higher order aberrations of the eye.

FIGS. 6A and 6B show more anatomical details of the above-mentionedembodiment in which a microfemtotomy 432 is used to secure the IOL 440of FIG. 5B within the lens capsule 402 by means of the anchors 442.

The anchoring capsulotomy need not be round, as shown in the previousexamples, and again in FIG. 7A. As non-limiting examples, FIGS. 7Athrough 7C show a few useful anchoring capsulotomy shapes that can beused. In general, any suitably shaped anchoring capsulotomy can be used.FIGS. 7B and 7C show two exemplary alternate configurations ofelliptical and rectangular anchoring capsulotomy shape perimeters. Anelliptical and/or a rectangular anchoring capsulotomy shaped perimetercan be used in the buttonhole concept mentioned above. The perimetersshown in FIGS. 7B and 7C contain both long and short margins.

The tip of each anchor may be inserted into a corresponding capsulotomyand pushed through to capture the anchor and hold the anchor in placeonce engaged. As such, the tip of the anchor should be overall largerthan the buttonhole incision of the anchoring capsulotomy. This can bethought of as analogous to a buttonhole holding a button. Alternately, abuttonhole capsulotomy can be constructed using a single linearincision. Such a linear incision can be made such that is tangential, orclose to tangential, to a circle describing the matching posts of theIOL to be implanted. Thus, the IOL can be implanted buy inserting eachpost individually, as opposed to requiring the posts to all be in moreor less in place as would be the case when the incisions are more orless perpendicular to a circle describing the location of the posts ofthe IOL to be implanted.

The incisions can also be made such that they are nominally linear andinclude rounded edges, forming a “bone-shaped” incision. Similarly, ateardrop-shaped or rounded-point-teardrop-shaped incision can also beformed.

In a further alternate embodiment, a small capsulotomy can be made suchthat it is substantially square, as opposed to rectangular. Although notshown in the accompanying figures, the corners of small capsulotomiescontaining substantially linear edges can be made rounded to minimizethe risk of capsular incision extension due to strain concentration atsharp corners. The creation of such small capsulotomies, especially withsmoothly rounded edges, is practically impossible to perform manually.

FIGS. 8A and 8B show an alternate embodiment wherein the IOL 440 to beimplanted is placed above an existing ocular lens 444. This isalternatively referred to herein as “piggybacking” and is particularlyuseful in cases where the removal of the existing ocular lens 444(either the natural crystalline lens or an artificial implant) is notaccomplished. The implantation of such an additional lens 440 may bedesirable in certain cases such as in cases of juvenile cataracts orother situations where the patient's refraction changes appreciably overtime. In such cases, even though the eye must be invaded, the risksassociated with removing an existing implant 444 are avoided byimplanting the IOL 440 over the existing lens 444 in the anteriorchamber. Such an IOL can be configured to improve the balance of thepatient's optical system. This can be achieved in cases of hyperopia andmyopia by the introduction of optical elements such as positive andnegative spherical lenses, respectively. Tonic elements such ascylindrical lenses, optical wedges and gradient index materials may alsobe used to correct astigmatism and even to address higher orderaberrations such as coma.

Furthermore, the placement accuracy afforded makes it possible toimplant optical elements in the eye of a patient to correct for numerousaberrations. For example, the patient's refraction can be determined bywavefront measurement or other suitable means and the optical correctionrequired to achieve emmetropia determined so that a customized opticalimplant can be designed. For convenience, we refer to the opticalimplant as an IOL, though it need not be a conventional lens. Thisimplant (IOL) can then be fabricated such that its implantationorientation is unambiguous. This can be achieved by the use of arotationally asymmetric configuration of anchors and mating anchoringcapsulomotomies such that IOL orientation is “keyed” or “clocked”, suchas those shown in FIGS. 9A-D. This way an IOL 440 can be placed in thecapsule of the eye such that it rotationally locates the IOL withrespect to the astigmatic axis of the eye. Such clocking may beaccomplished by providing a pattern of microfemtotomies 432A, 432B,432C, 434D such they form a rotationally asymmetric pattern, such as isshown in FIGS. 9C and 9D. This rotationally asymmetric pattern can bebeneficial to ensure that an axis of the IOL is aligned to the correctaxis of the eye and not 90 degrees or 120 degrees out of alignment, forexample. Alternately, the incision pattern may be made to form arotationally symmetric pattern, such as is shown in FIGS. 9A and 9B.Similar schemes can be employed, such as bilaterally symmetric andbilaterally asymmetric patterns. The patterns can be centered on theeye.

In many embodiments, the aberration axis 405 of the eye is aligned withthe aberration correcting axis 445 of the IOL. The pattern ofmicrofemtotomies 432A, 432B, 432C, 434D can be located on the capsule soas to align the aberration correcting axis 445 of the lens with theaberration axis 405 of the eye.

Rotational orientation of the IOL, or providing for rotational indexingabout the geometric or optical axes of the eye, can also be provided bymaking one of a plurality of the microfemtotomies different than theother microfemtotomies in the pattern. This affords the ability todistinguish the asymmetric axis of the eye and/or the IOL to beimplanted. With this distinction, a surgeon can locate matching featuresto assure the correct alignment of the IOL in the patient's eye. The IOLused to mate with these incisions can be made with posts that are notidentical to improve its clinical utility.

Similarly, the transverse location (i.e. the lateral location of themicrofemtotomies on the capsule can be used to improve the visualoutcome of the procedure. The presence of an asymmetric pupil or apseudo fovea may indicate a lateral alignment that is not as would beexpected otherwise. That is, such ophthalmic asymmetries would lead toIOL positions that would not be predicted by simply looking at theanatomy. The present system and method are particularly suited toaddress these anomalies because of the accuracy and flexibility affordedby the integration of anatomical imaging and laser capsulotomy creation,especially when the integrated imaging systems are used to provide forincision placement relative to anatomical landmarks or other suchfiducials.

This concept may be extended to accommodate the natural asymmetry ofcapsular contraction by orienting an asymmetric pattern of incisionsintended to engage with the posts of an IOL by locating the majority ofthe posts towards the direction of the lowest radial force.

Lens epithelial cells (LECs) that remain in the capsule after lensremoval can be problematic. The differentiation of LECs intofibroblast-like cells can cause wrinkles, folds, and opacities(“secondary cataract”) of the capsule and can result in posteriorcapsule opacification (PCO) and IOL decentralization. It has beenreported that Posterior capsule opacification causes a decrease invisual acuity in the first 5 years after cataract surgery in more than25% of patients. Over 2-4 weeks after surgery, the formation of fibroustissue in the capsule often occurs, pushing the lens back onto theposterior capsule. With conventional square-edged IOLs, a mechanicalbarrier to migrating LECs on the posterior edge of the lens is createdwhere the square edge barrier is located, such that the central visualfield is kept free of PCO. PCO may be avoided in two distinctlydifferent ways using the IOL devices described herein, and in a thirdway using an implanted drug-eluting device (such as a plug or pellet) tocombat PCO via the release of therapeutic agents such as thenon-limiting examples of diclofenac sodium, ketorolac tromethamine, andcytotoxic LEC-specific genes.

Tightly sealing the capsule to prevent the proliferation of lensepithelial cells that cause both opacification and mechanicalnonconformities in the capsule that serve to dislocate the IOL over timeand alter the patient's refractive correction may be accomplished byfabricating the mating IOL such that the lens forms a seal on thecapsule about each anchoring capsulotomy and also about the largercentral capsulotomy. A second approach is to maintain an open capsulethat is in fluid communication with the anterior chamber to minimize therisks instigating epithelial cell proliferation and/or differentiationby diluting the offending cytokines and other agents.

Most traditional IOLs do not consistently provide a completecircumferential seal due to the mechanical discontinuity of thelens-haptic junction. This fundamental limitation provides a pathway forLEC migration and subsequent PCO. Providing a sealed system using theanchoring capsulotomy mating IOL is more readily achieved in the absenceof these traditional haptics. Furthermore, a set of matching anchoringcapsulotomies can be made in the posterior capsule, as well. These willserve to collapse the capsule and improve the seal. It also has theadvantage of enabling the eye's accommodative processes to impart moreforce on the IOL to move it for improved focus.

Alternately, the present inventive IOL design can provide gaps betweenthe lens and the capsule, at least in places in order to maintain fluidcommunication between the capsule and the anterior chamber. This willallow for fluid to flow through the anterior chamber and the capsuleinterior. The non-limiting example IOL shown in FIG. 5B containsstandoff features 450 for this purpose. Other configurations are alsopossible, such as providing hollow channels within the anchoringfeatures 442, for example.

Alternately, the lens can be implanted within the anterior capsule, theposterior capsule, or both the anterior and posterior capsules. Thelatter is an alternative to what is known in the art as a “Bag-in-Lens”configuration that may better provide for the eye's accommodativeprocesses. Lenses implanted by the methods described herein may be madeintracapsularly on the anterior and/or posterior capsules, or on theanterior and/or posterior extremes of the capsule itself.

IOLs can be made to have axially symmetric posts for engaging with theanterior and posterior capsules. IOLs can also be made such that theposts are not axially symmetric. That is, the posts need not belaterally collocated, even as minor-images. As such, one can see thebases of all the posts when looking at an IOL from one face.

As mentioned above, alternate embodiments include the use of amicrofemtotomy to support a drug-eluting device instead of, or inaddition to, an IOL. There are many ongoing ophthalmic needs that arenot properly addressed by the present methods of time-release drugplacement. Non-limiting examples of this are glaucoma medications;anti-VEGF treatments; and the release of therapeutic agents such asdiclofenac sodium, ketorolac tromethamine, and cytotoxic LEC-specificgenes to combat PCO; as well as other compounds to improve the chemicaldiffusion or pumping of the cornea.

FIG. 10 shows an embodiment of a drug-eluting device implanted in ananchoring capsulotomy 432 a. In this example, drug-eluting device is aplug 500, which is implanted in the anchoring capsulotomy 432 a adjacentto a central capsulotomy 400 on the capsule 402. In this example, theplug 500 contains mechanical features designed to retain it in theanchoring capsulotomy 432 a.

The drug-eluting plug 500 shown in FIG. 11 has a cap 502 on a body 506,which ends at an end 504. Pores 510 are included on the body 506 toallow for dispersion of the drug that is otherwise contained withindrug-eluting plug 500. Example dimensions of the mechanical features ofdevice 500 are as follows:

Nominal Range of Feature Dimension Dimensions Units Cap 502, outerdiameter 2 0.5-4.0 mm Cap 502, thickness 0.5 0.1-1.0 mm Body 506, outerdiameter 1 1.0-3.0 mm Body 506, length 2 1.0-3.0 mm End 504, radius ofcurvature 0.5 0.125-4.0  mm

FIG. 12 shows a further alternate embodiment of a drug-eluting devicefor use with an anchoring capsulotomy. Although otherwise similar to theembodiment of FIG. 11, the embodiment shown in FIG. 12 includes theaddition of a waist 512 along the body 506 to provide for improvedretention of the device 500 within the anchoring capsulotomy 432.Alternately, a buttonhole capsulotomy can be used to provide enhancedretention and support of the device 500.

Similar to the device shown in FIGS. 5A through 6B, the alternateembodiment shown in FIG. 13A includes the addition of an end cap 514 toprovide improved retention within the anchoring capsulotomy 432. FIG.13B shows the same device deployed in an area of capsule that is notadjacent to the central capsulotomy.

FIG. 14 illustrates a method 600 for performing laser-assisted surgeryon an eye, in accordance with many embodiments. Any suitable system canbe used to practice the method 600, including any suitable systemdisclosed herein.

In step 602, an anchoring capsulotomy is formed in the lens capsule ofthe eye by using a laser to incise the lens capsule. The anchoringcapsulotomy is configured to accommodate an anchoring feature of anintraocular lens (IOL) using any suitable approach, for example, asdisclosed herein. In many embodiments, the anchoring feature protrudestransverse to a surface of the IOL that interfaces with the lens capsuleadjacent to the lens capsulotomy, such as illustrated in FIG. 6B. Theanchoring capsulotomy can have any suitable shape including, forexample, button hole, linear, bone-shaped, teardrop-shaped, round,rectangular with round corners, rectangular with sharp corners, andelliptical. Any suitable number of anchoring capsulotomies can be formedin the lens capsule. The one or more anchoring capsulotomies can beplaced in any suitable location such as, for example, in the anteriorcapsule, in the posterior capsule, and in both the anterior and theposterior capsules. Each of a plurality of anchoring capsulotomies canbe configured to accommodate a corresponding anchoring feature of anTOL. When multiple anchoring capsulotomies are used, the same ordifferent shapes can be used. In many embodiments, the anchoringcapsulotomies and the IOL are configured to orient the IOL relative tothe eye to provide correction of astigmatism of the eye. The anchoringcapsulotomies can be arranged such that the faun a suitable patternincluding, for example, a rotationally symmetric pattern, a rotationallyasymmetric pattern, a bilaterally symmetric pattern, and a bilaterallyasymmetric pattern. The asymmetry of the pattern can be oriented suchthat it corresponds to a direction of natural asymmetry of capsularcontraction. In many embodiments, at least one of the anchoringcapsulotomies is elongated tangential to a circle passing through theanchoring features of the IOL when the IOL is implanted. And at leastone of the anchoring features can protrude transverse to a surface ofthe IOL that interfaces with the lens capsule adjacent to thecorresponding anchoring capsulotomy.

In step 604, an anchoring feature of the IOL is coupled with theanchoring capsulotomy. The IOL can be placed in any suitable location.For example, the IOL can be placed within the anterior chamber, on orwithin the lens capsule, on the anterior side of the posterior capsule,and on the posterior side of the anterior capsule. The IOL can be a“piggyback” IOL. A second IOL can be coupled to the lens capsule so thatboth the IOL and the second IOL are coupled to the lens capsule. Thesecond IOL can be positioned anteriorly relative to the IOL. Theorientation of the second IOL relative to the lens capsule can berestrained using two or more anchoring capsulotomies created through thelens capsule with the laser.

Although the above steps show method 600 of treating an eye inaccordance with embodiments, a person of ordinary skill in the art willrecognize many variations based on the teaching described herein. Thesteps may be completed in a different order. Steps may be added ordeleted. Some of the steps may comprise sub-steps. Many of the steps maybe repeated as often as if beneficial to the treatment.

One or more of the steps of the method 600 may be performed with thecircuitry as described herein, for example one or more of the processoror logic circuitry such as the programmable array logic for fieldprogrammable gate array. The circuitry may be programmed to provide oneor more of the steps of method 600, and the program may comprise programinstructions stored on a computer readable memory or programmed steps ofthe logic circuitry such as the programmable array logic or the fieldprogrammable gate array, for example.

FIG. 15 illustrates a method 610 for performing laser-assisted surgeryon an eye, in accordance with many embodiments. Any suitable system canbe used to practice the method 610, including any suitable systemdisclosed herein.

In step 612, an anchoring capsulotomy is formed in the lens capsule ofthe eye by using a laser to incise the lens capsule. The anchoringcapsulotomy is configured to accommodate a drug-eluting member using anysuitable approach, for example, as disclosed herein. And more than oneanchoring capsulotomy configured to accommodate a drug-eluting membercan be formed and/or located in any suitable location including, forexample, in the anterior capsule, in the posterior capsule, or in boththe anterior and posterior capsules.

In step 614, the drug-eluting member is removably coupled to theanchoring capsulotomy. A mechanical feature of the drug-eluting membercan be removably fitted through the anchoring capsulotomy to retain thedrug-eluting member's position relative to the lens capsule. One or moreadditional drug-eluting members can be removably coupled withcorresponding additional anchoring capsulotomies,

Although the above steps show method 610 in accordance with embodiments,a person of ordinary skill in the art will recognize many variationsbased on the teaching described herein. The steps may be completed in adifferent order. Steps may be added or deleted. Some of the steps maycomprise sub-steps. Many of the steps may be repeated as often as ifbeneficial to the treatment.

One or more of the steps of the method 610 may be performed with thecircuitry as described herein, for example one or more of the processoror logic circuitry such as the programmable array logic for fieldprogrammable gate array. The circuitry may be programmed to provide oneor more of the steps of method 610, and the program may comprise programinstructions stored on a computer readable memory or programmed steps ofthe logic circuitry such as the programmable array logic or the fieldprogrammable gate array, for example.

FIG. 16 illustrates a method 650 of ophthalmic intervention, inaccordance with many embodiments. Any suitable system can be used topractice the method 650, including any suitable system disclosed herein.

In step 652, a pattern of anchoring capsulotomies is created in a lenscapsule of an eye. The pattern of anchoring capsulotomies is configuredto be mechanically coupled to anchoring features of an intraocular lens(IOL). Each anchoring capsulotomy of the pattern is configured toaccommodate a corresponding anchoring feature of the intraocular lens(IOL) using any suitable approach, for example, as disclosed herein. Inmany embodiments, at least one of the anchoring features of the patternprotrudes transverse to a surface of the IOL that interfaces with thelens capsule adjacent to the corresponding anchoring capsulotomy, suchas illustrated in FIG. 6B. The anchoring capsulotomies of the patterncan have any suitable shape. For example, at least one of the anchoringcapsulotomies of the pattern can have a buttonhole shape, a teardropshape, a round shape, a rectangular shape with sharp corners, arectangular shape with round corners, a linear shape, a bone shape, andan elliptical shape. In many embodiments, creating the pattern ofanchoring capsulotomies includes incising the lens capsule with a laser.

In step 654, a primary capsulotomy is created in the lens capsule. Theprimary capsulotomy can be an anterior capsulotomy, a posteriorcapsulotomy, and/or both an anterior capsulotomy and a posteriorcapsulotomy. The primary capsulotomy can be created to have any suitableboundary shape. For example, the boundary shape of the primarycapsulotomy can be circular, elliptical, polygonal, arcuate, and linear.In many embodiments, creating the primary capsulotomy includes incisingthe lens capsule with a laser.

The anchoring capsulotomies can be placed in any suitable locationsaround the primary capsulotomy. For example, the creation of the patternof anchoring capsulotomies can include placing two or more of theanchoring capsulotomies at locations substantially equivalently spacedapart about the boundary of the primary capsulotomy. The creation of thepattern of anchoring capsulotomies can include placing two or moreanchoring capsulotomies at locations non-homogeneously spaced apartabout the boundary of the primary capsulotomy. The pattern of anchoringcapsulotomies can be created to be rotationally symmetric, rotationallyasymmetric, bilaterally symmetric, or bilaterally asymmetric.

In step 656, a roll orientation to be established between the lenscapsule and the IOL is determined. For example, the determination of theroll orientation can include determining an astigmatic axis of the eyeand determining the roll orientation based at least in part upon theastigmatic axis of the eye. The anchoring capsulotomies of the patterncan be placed in locations configured to accomplish the determined rollorientation upon assembly of the IOL with the lens capsule. The rollorientation can be determined to correspond to a direction of naturalasymmetry of contraction of the lens capsule.

In step 658, a confirmation that the IOL is at the determined rollorientation relative to the lens capsule is accomplished before couplingthe IOL to the lens capsule. The roll orientation confirmation can beaccomplished in any suitable manner. For example, the roll orientationconfirmation can include observing a roll orientation of a keyed featureof the IOL. The roll orientation can include observing a rollorientation of a keyed feature of the lens capsule. The keyed feature ofthe IOL can be the relative positioning of the anchoring features. Forexample, in many embodiments, the pattern can be bisected along abisecting angle to result in two symmetric pattern halves and thebisecting angle can be used as the keying feature. The keyed feature onthe IOL can also be one or more keying markers created in the IOL. Thekeyed feature of the lens capsule can include one or more anatomiclandmarks of the lens capsule. The keyed feature of the lens capsule caninclude one or more markers created in the lens capsule.

In step 660, the IOL is coupled to the lens capsule by mechanicallyengaging the anchoring features of the IOL with the pattern of anchoringcapsulotomies in the lens capsule. When the IOL is coupled to the lenscapsule it can be located, for example, in an anterior chamber of theeye, in a capsular bag of the eye, on the anterior side of a posteriorcapsule of the eye, or on the posterior side of the anterior capsule ofthe eye.

Although the above steps show method 650 in accordance with embodiments,a person of ordinary skill in the art will recognize many variationsbased on the teaching described herein. The steps may be completed in adifferent order. Steps may be added or deleted. Some of the steps maycomprise sub-steps. Many of the steps may be repeated as often as ifbeneficial to the treatment.

One or more of the steps of the method 650 may be performed with thecircuitry as described herein, for example one or more of the processoror logic circuitry such as the programmable array logic for fieldprogrammable gate array. The circuitry may be programmed to provide oneor more of the steps of method 650, and the program may comprise programinstructions stored on a computer readable memory or programmed steps ofthe logic circuitry such as the programmable array logic or the fieldprogrammable gate array, for example.

Methods 600, 610 and 650 can be combined in one or more of many ways,for example one or more steps of each method can be combined, and thecombined steps may be completed in a different order, added or deleted,and some of the combined steps may comprise sub-steps, and may beimplemented with the circuitry as described herein.

While preferred embodiments of the present invention have been shown anddescribed herein, it will be obvious to those skilled in the art thatsuch embodiments are provided by way of example only. Numerousvariations, changes, and substitutions will now occur to those skilledin the art without departing from the invention. It should be understoodthat various alternatives to the embodiments of the invention describedherein may be employed in practicing the invention. It is intended thatthe following claims define the scope of the invention and that methodsand structures within the scope of these claims and their equivalents becovered thereby.

1.-28. (canceled)
 29. A system for performing a laser-assisted treatmentof an eye having a lens capsule, the system comprising: a laser sourceconfigured to produce a treatment beam comprising a plurality of laserpulses; an integrated optical system comprising an imaging assemblyoperatively coupled to a treatment laser delivery assembly such thatthey share at least one common optical element, the integrated opticalsystem being configured to acquire image information pertinent to one ormore targeted tissue structures and direct the treatment beam in athree-dimensional pattern to cause breakdown in at least one of thetargeted tissue structures; and a controller operatively coupled withthe laser source and the integrated optical system, the controller beingconfigured to control the system to cut an anchoring capsulotomy in thelens capsule, the anchoring capsulotomy being configured to accommodatea drug eluting member, wherein a mechanical feature of the drug elutingmember is configured to be removably fitted through the anchoringcapsulotomy to retain the drug eluting member's position relative to thelens capsule. 30.-51. (canceled)
 52. The system of claim 29, wherein thecontroller is further configured to control the system to cut a centralcapsulotomy in the lens capsule, wherein the anchoring capsulotomy isadjacent to the central capsulotomy.
 53. The system of claim 29, whereinthe controller is further configured to control the system to cut aplurality of anchoring capsulotomies, wherein the anchoringcapsulotomies are located in an anterior capsule of the eye, or in aposterior capsule of the eye, or in both the anterior and posteriorcapsules.